Family psychoeducation in the early stages of mood and psychotic disorders
Authors: David J. Miklowitz
Journal: World Psychiatry (2023)

When combined with pharmacotherapy, family psychoeducation and skills training are key strategies for preventing, delaying or minimizing the severity of illness episodes in major psychiatric disorders1-3. High levels of expressed emotion – as indicated by critical comments, hostility and/or emotional overinvolvement from caregivers – are associated with high rates of recurrence in patients with schizophrenia, bipolar disorder and major depressive disorder. These familial attitudes can become more negative and fixed as the disorders progress4. Early on in the illness trajectory, there is a window of opportunity for prevention or mitigation of disability in young persons. During this interval, patients and parents are usually most open to the collaborative approach of psychoeducation, in which they examine their thinking and behavior in relation to one another. Family psychoeducational interventions, however, have never completely “made it out of the shop”. Few practitioners have been trained in these methods. When psychoeducation is offered at all, it is usually in the form of unstructured support groups or canned didactic lectures. Moreover, support groups have limited reach: in a 2017 survey of 2,395 patient and caregiver respondents from the Depressive and Bipolar Support Alliance, a US-based support organization, 87% of persons with bipolar disorder were taking medications but only 10% attended support groups5. When adolescents or young adults first experience symptoms of mood or psychotic disorders, both they and their families are understandably confused as to what is happening. Parents have basic questions about the diagnosis, the likely course of symptoms over time, and what treatments are likely to be successful. Unfortunately, many clinicians simply provide didactic information in rote fashion, instead of assisting the family and the patient in negotiating the complex challenges of a new illness. What psychoeducational strategies help engage families and patients at these stages of illness development? Consider an 18-year old male, Zak, who has had an acute manic episode requiring hospitalization. Zak's father is able to describe the prodromal symptoms prior to his admission (e.g., rapid speech, irritable mood), but believes that his son has schizophrenia. His mother thinks that he is depressed. Zak thinks that there is nothing wrong with him. A psychoeducational family clinician will start with the provision of factual material: the key symptoms of mania and how they are different from those of a psychotic episode or normal teenage behavior. The clinician will personalize this information by encouraging Zak to describe the development of his symptoms and parents to chime in with their observations. The patient is identified as the “expert in the illness”, because “you can educate us as to what you've gone through and what might help you recover”. When their position in the family is elevated in this way, young people are more able to cope with the well-intended but often intrusive or critical comments of their relatives. Moving a step further, the clinician will encourage the parents and offspring to explore the practical application of Zak's diagnosis: what might be the early warning signs of new manic or depressive episodes? A paper or online mood chart6, completed daily by Zak and his parents, will help the family to become familiar with his patterns of mood shifts. The parents’ attributions about the causes of these fluctuations (e.g., “He has a biologically-based mood disorder” versus “He's lazy”) will be addressed. The clinician will gently challenge parents as to the usefulness of certain beliefs, especially those that lead them to become harsher or expect an unrealistically high level of functioning in their offspring. In a similar vein, families need help locating and evaluating the advantages and disadvantages of treatment options. They may be confused about how to decide on the intensity (e.g., weekly individual therapy vs. partial hospitalization) or type of care (e.g., pharmacotherapy, psychotherapy, or support groups). The parents may not agree on the need for medications or, if they do, they may not agree on what type or dosage is needed. They may need guidance in advocating for the child within the school system. Siblings may be confused as to their role in helping their ill brother or sister (or, at minimum, how not to trigger symptoms further). A different set of questions may haunt young affected people during this period. These issues surround how the illness will impact their peer and school relationships or activities, or even how their identity has been changed by the illness. They may express considerable resentment toward their parents for seemingly overreacting to minor symptoms or for insisting on a regimented lifestyle. These issues can become intertwined with the young persons’ struggle for autonomy. Psychiatric treatment may come to symbolize the last bastion of their parents’ control over them, with the psychiatrist seen as an agent of the parents. A key component of psychoeducation is the relapse prevention plan. The patient and the parents make a list of early warning signs of episodes and past stressors – major or minor – that appear to have triggered those episodes (e.g., the start of a new school year). Then, clinicians coach the family to make a list of potential coping strategies (e.g., try to regulate sleep and wake times) and potential obstacles to their implementation (e.g., foregoing late-night parties). The plan is modified over time as more data are collected on warning signs, eliciting stressors and effective coping strategies. In later segments of psychoeducation, clinicians attempt to modify levels of expressed emotion by guiding families in effective communication and problem-solving. Clinicians elicit role-play interchanges between parents and offspring with practice of skills such as active listening, making requests for changes in each other's behaviors, and balancing positive and negative feedback. To reduce parent/offspring criticisms (e.g., “I resent the hours you keep”), clinicians can take several steps: a) reframe the criticism as coming out of positive intentions (e.g., “I am worried about you not getting enough sleep and getting ill again”); b) point out that the parent's manner of delivery is inadvertently alienating the offspring; and c) model for the parent how he/she might make a request for behavior changes (e.g., “I'd appreciate your helping me manage my own anxiety by keeping to a regular bedtime”). These exchanges can be followed by problem-solving exercises in which family members offer practical input about how to keep consistent nightly routines. Severe family conflict often grows out of parents’ disappointments over failed expectations of the child. Input from the offspring about what they can or cannot accomplish while still symptomatic is essential. The offspring can be coached to make decisions that will enhance their chances of recovery (e.g., avoiding enrolling themselves in too many courses; discontinuing use of cannabis or psychostimulants). Recovery can be framed as an objective that must be achieved by the family as a whole, not only by the patient. Randomized clinical trials indicate that, among youth in the early stages of bipolar disorder, a 12-session, 4-month protocol of family-focused therapy (psychoeducation, communication training and problem-solving) is associated with shorter depressive episodes, longer periods of wellness between episodes, and less suicidal ideation and behavior than briefer forms of education1, 7. The broader availability of psychoeducational therapy may do much to reduce the long-term personal, familial and societal burdens imposed by severe psychiatric disorders.